*NURSING > SOAP NOTE > Episodic SOAP Note: Tom Walker|NRP 531,Latest 2020 complete, Already graded A (All)

Episodic SOAP Note: Tom Walker|NRP 531,Latest 2020 complete, Already graded A

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Running head: EPISODIC SOAP NOTE: TOM WALKER 1 Episodic SOAP Note: Tom Walker NRP 531 2021 Professor Sandra Brown EPISODIC SOAP NOTE: TOM WALKER 2 DOS: 4/15/2019 ID: Tom Walker (M) DOB:... 6/28/73 (45) CC: Atopic dermatitis (eczema) and right knee pain Subjective HPI: Tom is a 45-year-old Caucasian male who is deemed a reliable historian who presents with c/o an episodic flare of eczema which started a month ago (9/10) which is really bad in the bends of his arms and right knee pain which began four days ago after an injury playing basketball. He describes the itching being so bad it keeps him awake at night and his skin has little cracks that bleed. Aggravating factors include taking hot showers he reports he itches more after them. Relieving factors include mild improvement with OTC hydrocortisone cream. Tom reports he has had these flareups in the past. Tom reports that when the injury to his knee occurred, he heard a “pop” and was carried off the floor. He reports that he can not bear weight on his knee and has been using crutches to move around. Tom reports the swelling and bruising as intense and has been using ice, elevating the knee, wearing an ace bandage and taking Tylenol extra strength at the advice of his mother who is a nurse with mild improvement. Denies having fever, chills, weight gain or loss, dizziness, difficulty in swallowing, high blood pressure and depression. Past Medical History: Eczema. Surgical History: Arthroscopic meniscus repair 2009 in which he denies any pain prior to new injury and an appendectomy 8/18. Family History: Mother has high cholesterol and brother is obese with hypertension. Medications: Denies taking medication on regular basis but currently using OTC hydrocortisone crème for eczema and extra strength EPISODIC SOAP NOTE: TOM WALKER 3 Tylenol for knee pain. Allergies: NKDA. Social History: Alcohol use daily, patient reports drinking 4-6 beers every evening, patient is a non-smoker but stated he used marijuana one time in the past. Denies current elicit drug use. Patient reports daily caffeine intake and enjoyed out door sports. Patient education level: High School. Status: Employed as a maintenance man at a warehouse distribution center and is not married with no children. Questions and rationale: 1. Have you experienced knee pain before: Tom reported arthroscopic meniscus repair in 2009; did you have any knee pain prior to the new injury or after the meniscus repair in 2009? 2. When did the rash start? Tom reported a month ago. 3. Can you describe it? Tom reported the swelling and bruising as intense. 4. What makes it worse? For the eczema, Tom reported hot showers and for the knee pain Tom reports movement. 5. On a scale of 0-10, how would you describe your discomfort? Tom reported 9/10 for the eczema exacerbation. The rationale for utilizing open-ended questions when obtaining information about the chief complaint is the presence or absence of these symptoms will help develop a differential diagnosis which explains the patient’s condition (Bickley, Szilagyi & Hoffman, 2017). Objective PE: Vital Signs: BP- 120/78, P-70, R-16, T-98.2, HT: 72’WT: 250# BMI- 33.9 General: He is a well-nourished, well-groomed male who appears with distress as evidenced by sitting position and grimacing at times, Alert and Oriented x 3. Skin: Frontal scalp, face, neck, chest, abdomen, back, upper and lower extremities examined. Rash localized to the antecubital areas bilaterally with 1 to 2.5 cm, pink, very scaly plaques. EPISODIC SOAP NOTE: TOM WALKER 4 There is mild erythema with slight scale with fissuring that bleed in the antecubital areas bilaterally. CV: RRR. S1/S2. No murmurs, rubs, gallops, thrills, JVD, or edema. Pulm: Lungs clear to auscultation all bases, respirations non-labored with equal bilateral and A/P chest expansion. Abdomen: Soft, round, non-distended without pulsations. Bowel sounds normoactive x 4 quadrants. Musculoskeletal: Exam reveals the right knee is swollen with reduced ROM, no muscle atrophy evident, pain on resisted extension, decreased strength on extension against resistance, no patellar crepitus, joint line pain medially, McMurray positive for medial crepitus and pain, pain and swelling evident with palpation of the pes anserine bursa, ROM- flexion is limited and extension is limited, pain show medial collateral ligament pain and laxity, positive abduction (valgus) stress test. McMurray Test: The patient was in the supine position while test was performed. Palpable “pop” noted along the medial joint line, indicative for a positive test for a tear of the posterior portion of the medial meniscus (Bickley, Szilagyi & Hoffman, 2017). [Show More]

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